‘The medicine sellers have become the hospital now': Health service responses to violence against women during the Ebola and COVID-19 outbreaks in Sierra Leone

Introduction: Outbreaks and violence against women (VAW) are interlinked public health challenges, yet health system responses for VAW during outbreaks remain poorly understood. We sought to understand how and to what extent health services for VAW in Sierra Leone were delivered by health providers and communities during the 2014-2016 Ebola outbreak and the COVID-19 pandemic.

Methods: Thirty-seven in-depth interviews and four focus group discussions were conducted in Freetown and Kambia in Sierra Leone in 2022 with health service providers, outbreak actors, community members, and women who had experienced physical or sexual violence during the Ebola or COVID-19 outbreaks. Data were analysed thematically.

Findings: Many participants described the exacerbation of long-term health system challenges during the outbreaks, with survivors of violence facing under-resourced, broken or corrupt government health services. Especially during the Ebola outbreak, systems of care for VAW survivors were reconfigured with the role of informal health actors such as medicine sellers and traditional healers amplified. VAW providers described adaptations to health service delivery and ways that they tried to cope with difficult working conditions: plugging gaps in commodity supplies, adopting infection prevention and control protocols or making personal sacrifices so that systems functioned. Whilst VAW health services faced significant challenges continuing to provide care, they were overlooked by the outbreak response.

Conclusions: The outbreaks, especially Ebola, meant ‘normal’ service delivery challenges for VAW were heightened. These findings highlight the need to integrate VAW services into outbreak preparedness and response efforts, including through leveraging informal actors.